Hair Transplants for Frontal Fibrosing Alopecia: Pre-op Expectations are Key!

Long Term Hair Transplant Outcomes are Good but Not Fabulous in Stable FFA

Hair transplantation may be a treatment option for stable FFA. I’ve reviewed the criteria before regarding when a person should and should not be given the “green light” to proceed to surgery

FFA HAIR TRANPSLANT CRITERIA

Vano-Galvan et al, 2019

If you speak about FFA and surgery in the same sentence, then you should ideally be aware of the 2019 study by Vano-Galvan and collegues. They present a nice analysis of hair transplant outcomes of patients with FFA who underwent hair transplant surgery.

A total of 51 patients (48 females and 3 males) with a mean age of 54 years and a mean grade of severity score of 2.3 out of 5 were included in their study. The hair transplant surgery was done after a mean time of stabilization of the disease of 15 months (range, 0-60). They defined stabilization was no progression of the alopecia on the frontotemporal hairline after 12 months and by trichoscopy (absence of peripilar casts).

The strip (FUSS) technique was performed in 44 patients (86%), and the follicular unit extraction (FUE) technique was performed in 7 patients (14%). The mean number of transplanted grafts per surgical procedure was 1345 follicular units so one must take note that these are more conservative procedures.

The most frequent location of the HT was the temporal area in 59 % of patients and the frontal area in 44 % and eyebrows in 29 %. Patients were followed for a mean of 3.2 years after surgery (range was 2 to up to 10 years). The authors point out that all patients received some sort of medical therapy after their transplant

What was graft survival like after hair transplants in FFA patients?

Graft survival in stable FFA patients were pretty good at one year with 87 % of follicular units surviving. This reduced fairly steadily to 41 % survival after 5 years. In the 12 patients that the authors followed for more than 12 years, survival was less than 60 % in all those patients.

Factors Associated with Graft Survival

The authors could not detect any clear parameters that predicated graft survival. There were no differences in graft survival by the type of technique employed (FUE vs FUSS) or by location where the grafts were placed (temples, hairline eyebrows).

In addition, a longer time between stabilization of FFA and surgery was not associated with higher survival of the grafts.

Disease Activation

Although the grafts were slowly destroyed over the 5 years of study, the authors felt there was no significant worsening or reactivation of the underlying disease was detected in any patient.

Satisfaction is High with Hair Transplant Surgery

Of the 51 patients, 42 (82%) were satisfied with the HT.

Comment

This is a really important study to understand. We should definitely not be doing surgery on patients with active FFA disease, but once it’s inactive surgery becomes a possible option. My personal feeling is waiting 2 years is ideal but not everyone agrees with this. One year is far to short in my opinion. FFA can be incredibly slow moving and photos over 1 year might not show loss but photos over 2 years might show loss.

This paper reminds us that transplanted grafts are going to die. We need to be ready for this. But a high proportion of patients are satisfied with their hair transplant outcomes. So provided we set clear expectations for our patients on what to expect, many will be pleased. About 1 in 5 patients will be somewhat disappointed with the procedure.

The paper also reminds us that staying on treatment is important. At one time, I felt that once the disease is quiet, one can go off medications. that’s somewhat true is one has stable FFA and does not want surgery. however, if one’s goal is hair transplant surgery staying on medications is probably the best plan for long term success. Tis paper does not elaborate in detail on the types of treatment but this is an important subject for the future. My personal belief is that our best outcomes are in those who remain on 5 alpha reductase inhibitors (and maybe minoxidil) before, during and after the transplant.

Hair Transplant Surgery for FFA: The Spectrum of Candidates

Patients with FFA are never “good” or “bad” candidates for surgery. There is a wide spectrum ranging from amazingly good to amazingly bad. I have reviewed this before in other articles, but a summary is presented here. The ideal candidate is one who remains on therapy and who has already proven the disease to be stable with prior surgeries. Of course, this is a rare event. The second best candidate is someone with stable disease for 2 years and who remains on therapy.

REFERENCE

Vano-Galvan S et al. Hair transplant in frontal fibrosing alopecia: A multicenter review of 51 patients. J Am Acad Dermatol. 2019 Sep;81(3):865-866.